2025 Home Renewal Questionnaire

1
Name* This field is required.
First Name
Last Name
2
Best Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Do we have permission to communicate via text with you at this number?* This field is required.
Yes
No
5
Have you moved within the last year?* This field is required.
Yes
No
6
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Marital Status
Please Select
Please Select
Married
Single
Divorced
8
Occupation?
9
Secondary Insured
First Name
Last Name
10
Secondary Insured's Date of Birth
Date
Month
Day
Year
11
Secondary Insured's Best Email
example@example.com
12
Secondary Insured's Phone Number
Please enter a valid phone number.
13
Do we have permission to communicate via text with you at this number?* This field is required.
Yes
No
14
Have you made any updates to the home in the past 5 years?* This field is required.
Yes
No
15
What was updated?* This field is required.
Roof
Plumbing
Electrical
Furnace/AC
Other
16
what year was your plumbing updated?* This field is required.
17
what year was your electrical updated?* This field is required.
18
what year was your furnace/AC updated?* This field is required.
19
What year were your other updates completed?* This field is required.Include the description of the type of update
20
What year was the roof last updated?
21
Any repairs needed to the dwelling (chipping/peeling paint, broken windows, etc)?* This field is required.
Yes
No
22
Please list the repairs needed:* This field is required.
23
Property free of clutter? (i.e. inoperable vehicles, construction debris, tires, appliances)* This field is required.
Yes
No
24
Solid fuel heat device? (i.e. pellet or wood stove)* This field is required.
Yes
No
25
Pets?* This field is required.
Yes
No
26
Breed of Dogs?
27
Any vicious bite history?* This field is required.
Yes
No
28
Horses, livestock, or farming income?* This field is required.
Yes
No
29
Trampoline or a pool?* This field is required.
Yes
No
30
Pool?* This field is required.
Yes
No
31
Business at home?* This field is required.
Yes
No
32
Any farming income?* This field is required.
Yes
No
33
Do you own any additional properties that need insurance (rental, vacation, commercial)?* This field is required.
Yes
No
34
What is the primary use of any additional properties?Select all that apply
Secondary Home
Vacation Rental
Short-Term Rental (Less than 6 months)
Long-Term Rental (Greater than 6 months)
Commercial Property
35
Do you have auto insurance with our agency?* This field is required.
Yes
No
36
Have there been any changes (e.g., new drivers or vehicles, or usage- ex. Uber/Lyft) since your last renewal?* This field is required.
Yes
No
37
Describe the changes that have occurred since your last renewal.* This field is required.
38
Can you access your current policy online?* This field is required.
YESNO
39
To make sure we’re showing you the most competitive options, we’re currently quoting home and auto together as a bundle. This often leads to better pricing and broader coverage across the carriers we work with. We’ve already got your home details—now we just need a quick look at your auto info to get everything quoted accurately. If you don’t have your login, no worries—just contact your auto carrier for a copy of your declarations page and email it to us at service@smithfamilyagency.com.
40
Please upload current declarations page if availableIf you don't have your current declarations pages, please contact your carriers for a copy of your declarations page and email us: service@smithfamilyagency.com
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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41
Any additional notes you would like us to know?
Should be Empty: